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OD2 Semester 2 - Applied Clinical Training > wk4: AED - Conjunctival Degeneration > Flashcards

wk4: AED - Conjunctival Degeneration Flashcards

1
Q

What does the SOAP mnemonic stand for?

A

S - Subjective (symptoms)
O - Objective (signs)
A - Assessment (DDx/DEx + tests for Dx)
P - Plan (Mx)

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2
Q

What 3 parts of the conjunctiva are responsible for secreting mucin?

A

Goblet Cells
Crypts of Henle
Glands of Manz

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3
Q

What are crypts of henle?

A

microscopic pockets (that secrete mucin) found in scattered sections of the conjunctiva

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4
Q

What are glands of manz?

A

an anatomical structure (that secretes mucin) in the conjunctiva arranged in a ring around the cornea, near the scleral junction

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5
Q

What are goblet cells?

A

a column-shaped cell that secretes mucin

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6
Q

What is mucin? What does it do for the eye?

A

a proteinous substances that makes up the inner layer of tears. It coats the cornea to provide a hydrophilic layer that allows for even distribution of the tear film

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7
Q

What happens to the tear film if mucin producing components malfunction?

A

unstable tear film

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8
Q

How thick is the conjunctival epithelium?

A

2-10 cell layers thick

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9
Q

What do the glands of kraus and glands of wolfring do?

A

They are accessory lacrimal glands. The function of both is to produce tears which are secreted onto the surface of the conjunctiva. They are known as basal lacrimal secretors (i.e. basal tears)

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10
Q

Where in the conjunctiva are the accessory lacrimal glands found?

A

stroma

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11
Q

Describe the structure of the conjunctival stroma

A

vascular connective tissue

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12
Q

How many glands of krause are located in the superior and inferior conjunctival fornix (own study)?

A

Superior: 20
Inferior: about 10

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13
Q

What happens to the tear film if superior and inferior fornix is inflamed?

A

Unstable tear film - because glands of krause are affected since some of them are located there

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14
Q

Define Pingueculum

A

a benign, non-cancerous, yellowish deposit on the conjunctiva

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15
Q

Name 3 signs that a patient has pingueculum

A
  1. triangular (base toward limbus) yellowish, slightly elevated mass on nasal or temporal sclera - sometimes like discrete gelatinous deposits
  2. very common + generally bilateral (3 o’clock and 9 o’clock)
  3. not vascular, but can be hyperaemic if inflamed
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16
Q

What is hyperaemia?

A

excess of blood in a body part (as from an increased flow of blood due to vasodilation)

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17
Q

Describe the symptoms of pingueculum (4)

A

usually asymptomatic - but can cause dry eye
cosmetically unappealing
foreign body sensation if inflamed
no affect on vision

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18
Q

Is pingueculum a growth?

A

It’s not a growth, per-say, it’s a deposit

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19
Q

In what orientation does the triangular appearance of a pingueculum present on the conjunctiva?

A

The base of the triangle is at the limbus

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20
Q

How can we assess pingueculum? (4)

A

Slit Lamp
Fluoroscein stain (?dellen)
Tear workup (if symptoms)
Document

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21
Q

How can pingueculum cause dry eye?

A

As the mass is raised above the tear film, the tissue next to it dries, which can result in a dellen (sterile ulcer as the tissue dissolves away)

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22
Q

What is the main cause of pingueculum?

A

Genetic

note: age is not significant

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23
Q

Describe the histopathology of pingueculum (4)

A

Elastotic (elastin tissue breakdown) degeneration of the collagen
Hyalinization of the conjunctival stroma
Collection of elastotic fibres
Granular deposits

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24
Q

What conditions should pingueculum be differentially diagnosed from? [4]

A

pterygium
conj. intraepithelial neoplasia (CIN)
other tumours (e.g. papilloma)
limbal dermoid

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25
Q

How might we treat pingueculum? [5]

A

Leave it - in vast majority of patients
Vasoconstrictors - to reduce redness; useless in chronic (repeat after me: useless)
Ocular lubricants, cold compresses: if FB sensation
NSAIDs or topical steroids - if severe inflammation
Cosmetic surgery = last resort

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26
Q

If you choose not to treat a patient with pingueculum, what advice can you give a patient to help manage it?

A

Glasses/sunglasses when outside to protect against wind. Wind dries out eyes and will dry out the raised mass/surroundings even more. Wraparound glasses are particularly good protection here

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27
Q

Is UV exposure a risk for pingueculum?

A

NO it is not!

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28
Q

When do we schedule a follow up for a patient with pingueculum?

A

At a normal review time, unless patient requests earlier if diagnosis uncertain

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29
Q

What side effect might the use of NSAIDs in treating chronic pingueculum lead to?

A

stomach ulcers

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30
Q

How can you differentially diagnose the following conditions from pingueculum?
Dermoid, Papilloma, CIN

A

Dermoid: internal blood vessel structure, variation of own tissue
Papilloma: more spongey, blood vessel structure within them
CIN: sits on top of everything and continues to grow

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31
Q

Why might we not be inclined to remove pingueculum?

A

Surgical removal is very painful! Conjunctival healing is uncomfortable and hard to anaesthesize!

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32
Q

Describe the process of surgical removal of pingueculum [4]

A
  1. excision including overlying conjunctiva
  2. wound closure with suture
  3. amniotic membrane for larger wound
  4. prophylactic topical antibiotic + anti steroid (pred forte)
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33
Q

How does an argon laser work for pingueculum removal?

A

photocoagulation of pingueculum, followed by prophylactic topical antibiotic + anti steroid (pred forte)

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34
Q

What is Pterygium? [4]

A

a pinkish, triangular tissue growth on the cornea of the eye., similar to pingueculum

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35
Q

List 6 signs that a patient has pterygium

A
  1. vascular triangular mass of tissue (base to conj.), generally on nasal conj + cornea
  2. may be slowly growing/advancing toward central cornea
  3. often bilateral, can be medial + temporal together
  4. may have orange-brown (iron deposits) line at leading edge (stocker’s line)
  5. opaque epithelium, overlying defect in front of leading edge
  6. increasing astigmatism
36
Q

Name 4 symptoms of pterygium

A

cosmetically unappealing
FB sensation, dryness
reduction in vision if encroaching on visual axis or increasing cyl
rarely diplopia (monocular)

37
Q

How can we assess pterygium? [4]

A

Slit lamp, keratometry/topography
Fluoroscein staining
Tear workup if indicated
Document (photo or measurment, grading scales)

38
Q

How do we treat pterygium? [3]

A

vasoconstrictors to reduce redness?
ocular lubricants - for ocular irritation + corneal signs
topical steroid or NSAID - for severe irritation

39
Q

Under what scenarios should we refer pterygium for surgical removal? [5]

A 
if:
advancing rapidly
chronic irritation
diplopia
marked effect on vision
cosmesis concern
40
Q

Describe the pathophysiology of pterygium [3]

A

Activated fibroblasts in leading edge of pterygium invade + fragment bowman’s layer + a variable amount of superficial corneal stroma

41
Q

Describe the histology of pterygium development [1]

A

resembles actinic degeneration of the skin

42
Q

When do we schedule a follow up for a pterygium patient?

A

Depends on rate of progression:
If stable: review in 1-2 years
If progressive or new patient: review in 3-6 months

43
Q

Is UV exposure a risk for pterygium?

A

YES

44
Q

Can pterygium regrow after surgery?

A

yes

45
Q

How does the timing of pterygium removal affect the likelihood of a successful outcome?

A

earlier the removal, better the result

46
Q

What are the 2 main aims of pterygium surgery?

A

Remove pterygium

Prevent recurrence

47
Q

Why is a wide excision necessary in pterygium surgery?

A

to reduce recurrence

48
Q

What is the standard surgical removal technique for pterygium?

A

bare scleral resection

49
Q

How can an autograph/primary closure surgery be useful for pterygium?

A

Useful as an adjunct treatment alongside bare scleral resection. Helps prevent recurrence.

50
Q

Name 3 adjunct treatments that can be used to minimise recurrence of pterygium

A

autogroph/primary closure surgery
mitomycin C
beta irradiation

51
Q

Describe the conjunctival autograph surgery. How does it work?

A

tissue transplant from upper eyelid fills the gap in the conjunctiva where the pterygium was removed

52
Q 
What is the recurrence rates of pterygium for the following removal treatments:
Base Sclera
Beta irradiation
Mitmycin C
Autoconjunctival graph
A

Base sclera: up to 80%
Beta irradiation: less than 10%
Mitomycin C: less than 10%
Autoconjunctival graph: 7%

53
Q

In what type of patients do concretions most typically occur?

A

people with systemic or topical chronic inflammation

54
Q

What is a concretion?

A

a hard solid mass formed by the local accumulation of matter, especially within the body or within a mass of sediment.

55
Q

List 4 signs of concretions

A
  1. yellow-white, usually <1mm (but up to 4mm) deposits in palpebral conjunctival epithelium + epithelium of inferior fornix
  2. common in elderly - ?mucin and necrotic cells/eosinophilic proteins, etc.
  3. may be assoc. with chronic conjunctivitis, CL wear
  4. may see associated clear cyst
56
Q

Describe the symptoms of concretions [2]

A

generally asymptomatic

may have ‘gritty’ FB sensation

57
Q

How can we assess concretions? [2]

A

Slit lamp

Fluorescein stain for erosion

58
Q

Name 3 conditions that need to be differentially diagnosed from concretions

A

other FBs
conjunctival cysts
conjunctival trauma

59
Q

How can we treat concretions? [5]

A 
monitor if asymptomatic (tx if symptoms)
review CL care + assoc env factors
ocular lubricants
removal: using anaesthesia + needle (e.g. 25G)
prophylactic antibiotic after removal
60
Q

When should we schedule a follow up for a concretions patient?

A

If not removed: schedule at px request

if removed: 3-5 days after

61
Q

What is Amyloidosis?

A

deposition of amyloid in the body.

62
Q

List 4 signs of amyloidosis in the eye

A
  1. yellowish, avascular, waxy deposits within the bulbar or forniceal conjunctival - can be assoc. with recurrent bleeding
  2. material is amyloid (an accumulation of a variety of proteins of differing origins)
  3. usually unilateral - may be primarily (usually in conjunctiva) or secondary (e.g. to TB)
  4. may be a localised (usually for conj) or systemic disorder
63
Q

What might we ask in patient history about systemic issues if we suspect amyloidosis?

A

ask about lung complaints, because can be secondary to tuberculosis

64
Q

Describe the symptoms of amyloidosis [3]

A

usually asymptomatic in the eye deposits, not tender unless large enough to affect lid function or give FB sensation

65
Q

How can we treat amyloidosis? [3]

A

Check if amyloid present elsewhere in eye (e.g. lids, ant. chamber, optic nerve, cornea, iris, lacrimal gland)
Removal required if FB sensation or for cosmesis
Refer for biopsy (if diagnosis uncertain), removal, or to rule out systemic amyloidosis

66
Q

When should we schedule a follow up in amyloidosis patient?

A

early if doubt over diagnosis, change in size or symptoms

67
Q

List 4 signs of conjunctival cysts

A
  1. typically small clear cyst (bubble) within bulbar, forniceal, or palpebral conjunctiva (2-5mm)
  2. or tube-like swelling of bulbar lymphatic (may be multiple) which is more transparent than cyst
  3. mobile to touch and with blink
  4. usually unilateral
68
Q

List 2 symptoms of conjunctival cysts

A

typically asymptomatic, may have FB sensation

patient frequently cosmetically concerned

69
Q

How can we assess conjunctival cysts? [2]

A

Slit lamp

Document

70
Q

What is conjunctivochalasis?

A

excess redundant tissue in conjunctiva (is a DDx for conjunctival cysts, and some other stuff)

71
Q

How can we treat conjunctival cysts? [4]

A

usually monitor if asymptomatic
lance cyst (25G needle + anaethesia), massage closed lid to drain, but will usually re-occur
prophylactic antibiotic required
refer for surgical removal from base if required

72
Q

When do we schedule follow up in conjunctival cyst patients?

A

to monitor if lanced and antibiotic prescribed

at patient request

73
Q

List 4 signs of ecchymosis

A
  1. sub-conjunctival blood anywhere under the bulbar conjunctiva
  2. distinct white border at limbus and conjunctival fornix (posterior limit)
  3. very common, usually unilateral, (aka sub-conj haemorrhage)
  4. most idiopathic but must exclude precipitating event
74
Q

Name 2 symptoms of ecchymosis

A

painless and no affect on vision (by itself)

if associated with trauma: other assoc. symptoms likely present

75
Q

How do we assess ecchymosis? [3]

A

Hx for any precipitating event (e.g. trauma, hypertension)
Slit lamp (AC and internal exam depending on hx)
Pupils, eye movements, IOP (depending on hx), blood pressure

76
Q

What 4 conditions should we DDx with ecchymosis?

A

conjunctival kaposi’s sarcoma
haemorrhagic (or other) conjunctivitis
breakthrough bleed from behind globe
other ocular neoplasia with secondary haemorrhage

77
Q

How can we treat ecchymosis? [4]

A

if traumatic, manage as appropriate
reassure patient
cold packs: to stop bleed in first 1-2 days, followed by hot packs assisting haemolysis
may take 1-3 weeks to resolve

78
Q

When should we schedule a follow up in ecchymosis patient? [2]

A

1 week: if concerned or no resolution

Also schedule if: more than 2 recurrences in 1 year - to determine if systemic cause determination or cauterisation

79
Q

What are bitot’s spots?

A

Bitot’s spots are buildup of keratin located superficially in the conjunctiva of human´s eyes.

80
Q

List 6 signs of bitot’s spots

A
  1. ‘foamy’ slightly raised patches on temporal bulbar conjunctiva
  2. due to metaplastic keratinisation of conjunctival epithelium and loss of goblet cells
  3. usually temporal, less frequently nasal
  4. hyperkeratinisation of local area assoc. with colonisation by corynebacterium
  5. assoc with Vitamin A deficiency
  6. uncommon in aus
81
Q

Name 3 symptoms of bitot’s spots

A

ocular surface irritation
reduced vision
nightblindness assoc.

82
Q

How do we assess bitot’s spots? [3]

A

Slit lamp
dry eye workup
document

83
Q

How can we treat bitot spot?

A

Refer to GP for blood test to confirm vit A deficiency
High dose Vit A therapy - can normally make it disappear
May regress within weeks, if longstanding, may have permanent epithelial metaplasia and so will remain
Manage dry eye symptoms as appropriate

84
Q

Is there any way the patient can manage early bitot spot?

A

a change in diet may be sufficient

85
Q

When do we schedule follow up in bitot spot patient? [2]

A

over period of vitamin A therapy

if change in size or symptoms

86
Q

Still have a few more slides to go

A

how annoying

OD2 Semester 2 - Applied Clinical Training (63 decks)

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